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DHRM Form 10-012
(Rev. 9/03)
Please print in ink (preferably black) or use typewriter
Number
of attachments
Position number
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Commonwealth
of Virginia
An Equal Opportunity Employer
Application for Employment
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Send
this application
directly to the
agency
announcing
the vacancy.
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Employees
of the Commonwealth and applicants for employment shall be afforded equal
opportunity in all aspects of employment without regard to race, color,
religion, political affiliation, national origin, disability, marital status,
gender or age.
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As
a means of accommodation to persons with specific disabilities that prevent
them from completing this application, confidential assistance in filling out
this application may be obtained by calling the agency to which you are
applying.
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1. Position applied for
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2. Agency
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(one
per application)
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(Note: Completion
of number three is optional. Failure
to submit social
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3. Social Security No.
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security number on this form will not prohibit
employment consideration.
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Social security number may be required on other forms
prior to employment.)
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4. Full legal name
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6. Home Phone
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( )
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Last
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First
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Middle
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5. Address
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7. Business Phone
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( )
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8. E-mail
Address
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City
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State
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Zip
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9. EDUCATION
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a. Check
highest grade completed
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1 2 3 4 5 6 7 8 9 10 11 12
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b. If you did not complete high school, do you
have a high school equivalency diploma?
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Yes
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No
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c. Check number of years of post high school
education
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1
2
3
4
5
6
7
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Name and Location of
Institution
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Hrs
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Degree
Received
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Major
or Specialty
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Minor
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Dates
Attended
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1.
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2.
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3.
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d. If you expect to complete an educational
program in the near future, please indicate what type of degree or program
and expected
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completion
date:
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10. EXPERIENCE — Use Supplementary Experience Form(s)
for additional space. Starting with the most recent, describe
ALL paid, military and applicable
voluntary experience. Highlight your knowledge, skills and abilities which
best demonstrate your qualifications for this position.
You
may list significantly different jobs within the same organization as
separate items. May we contact your
present supervisor? Yes No
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a. Job
Title
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Duties:
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Employer
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Address
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Phone
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Type
of business
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Immediate
supervisor
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Title
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Number and titles of
employees you supervised
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Salary
(start)
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(finish)
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Equipment used
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Dates
(mo/yr)
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